Circumcision's benefits outweigh risks, doctors' group says

Andrea K. Walker, The Baltimore Sun

The American Academy of Pediatrics is modifying its stance on circumcision for the first time in more than a decade, acknowledging that the health benefits outweigh the risks of the procedure, which involves removing the foreskin of a baby boy's penis.

In new recommendations it plans to announce Monday, the group doesn't go as far as suggesting that all babies should have the operation. But when parents choose it for their sons, insurance companies and state Medicaid programs should pay for it, the academy now says.

A member of the AAP task force said that the group is not taking a side on the highly debated issue, but wanted parents who choose the procedure not to feel guilty.

"There is enough benefit that parents should be allowed to do it and not feel like they're committing some horrible crime against their family," said Dr. Andrew Freedman, a Los Angeles-based pediatric urologist. "If families don't want to do it they shouldn't feel bad either."

The doctors' group has remained neutral on the controversial issue for years. It last updated its position in 2005, reaffirming a stance from 1999 that there wasn't enough scientific evidence to show medical benefits to recommend circumcision.

The change in opinion puts it at the forefront of a polarizing topic that pits those who think circumcision is necessary to ward off disease against those who call it a painful and unnecessary cosmetic procedure with no real health benefits.

Physicians use the academy's recommendations to help decide how they treat and advise their patients. The group also can be highly influential at the policy level, with local and federal government officials looking for its insight on legislative health issues.

The academy said in a more than 30-page report that scientific studies in the past 13 years on the health benefits of circumcision helped drive its decision, including three recent studies that found circumcision reduced the spread of HIV in Africa. It formed a task force in 2007 to study the issue as growing evidence showed circumcisions prevent urinary tract infections in infants and protect against sexually transmitted diseases in adults.

Freedman said the newest recommendations aren't much different than previous stances, but people on both sides of the debate saw them differently.

Proponents of circumcision welcomed the academy's new recommendations, saying they have the potential to have a huge public health impact and over time could save the country billions of dollars in medical costs.

"They have clearly reversed their policy on male circumcision and recognized the public health benefit of the procedure and that is very good news," said Dr. Aaron Tobian, a Johns Hopkins University epidemiologist and pathologist, who said parents will now get a full picture from doctors of the benefits of circumcision.

Tobian co-wrote a study released last week that found that a 20-year decline in male circumcision has cost the country $2 billion in medical costs that could have been prevented. Some studies have found uncircumcised men are more at risk for cancer-causing HPV, HIV, herpes, bacterial infections and other sexually transmitted diseases. It is believed bacteria and viruses can get trapped in the extra layers of skin left on the penis.

Those on the other side of the debate said the academy is ignoring just as many studies that dispute that men who are circumcised are better protected from certain illnesses. Many said it shouldn't be the parents' decision and instead boys should decide later in life whether to be circumcised.

"There is so much information that contradicts what they say that it is just mind-boggling," said Georganne Chapin, executive director of Intact America, a group that advocates against circumcision of boy babies.

Chapin and other opponents of the procedure said that it is painful and unnatural and in the long term results in decreased sexual pleasure and psychological problems. They said there are complications with circumcisions that can also be costly, including botched procedures.

Meredith Lovell-Thayer, a 27-year-old apprentice midwife from Frostburg, decided not to have her son circumcised after reading literature about the pain babies endure.

"I couldn't consciously do that to my child," said Lovell-Thayer, whose son is now 20 months old.

She said she is disappointed in the academy's stance. In Europe, where only 10 percent of men are circumcised, she said, STDs aren't rampant.

Support for circumcision in America has been declining since the 1970s. Today, about 55 percent of the 2 million baby boys born each year are circumcised, compared with a peak of 79 percent in the 1970s and 1980s.

Some families are choosing to forgo the procedure for personal reasons. Eighteen states have stopped paying for babies of poor families to have the procedure under Medicaid. Maryland is not among those states.

Tobian, the Hopkins researcher, and others think the drop in coverage by Medicaid, which covers two-fifths of all births, may be deterring some parents from having their babies circumcised. A circumcision costs between $216 and $601, which may seem expensive to a family trying to make ends meet. The academy agreed that financial barriers like this need to be addressed.

But the group took careful consideration not to step on the cultural and personal beliefs of parents. Many Muslims and Jews perform circumcisions as a religious rite. They are fighting bans on the procedure in some countries in Europe based on freedom of religion.

The health benefits aren't enough to recommend that all parents choose the procedure, the academy said. The group said that physicians should tell parents of the procedure's risks and benefits in an unbiased manner so they can make the most informed decision.

"They will need to weigh medical information in the context of their own religious, ethical and cultural beliefs and practices," the academy wrote in its report. "The medical benefits alone may not outweigh these other considerations for individual families."

"We recognize the medical aspects are just one element," Freedman said. "We recognize as physicians that we can weigh in medically, but we are not the best to weigh in on all the other paradigms in a person's life."

To cut down on complications, circumcisions should be done by trained physicians and only on babies who are stable and healthy, the group recommends. It said there aren't enough studies to determine the true number of complications after circumcision. Significant acute complications are rare, occurring in 1 in 500 newborn circumcisions, the academy's analysis found.

The group said further study should be done on the link between circumcision and HIV in the United States. Current studies were done in Africa. They also said more research is needed to determine the effectiveness of circumcision during infancy, complications associated with the procedure and comparing the effectiveness of circumcision during infancy with procedures done later in life.

"Mostly we are trying to clarify the concept that we're not coming out saying that nobody should be circumcised or everybody should be circumcised," Freedman said. "We recognize that circumcision has a place in a child's life for some families. For other families it might not."